General surgery expert witness advises on nicked ureter that required additional surgery

A general surgery expert witness advises on a case involving a patient who suffered a nicked ureter during a surgical procedure. Plaintiff presented to the emergency department with complaints of nausea, dry heaves, poor oral intake and constipation. A CT scan of the abdomen showed a constricting lesion within the sigmoid colon. She was admitted and underwent an uneventful open sigmoid colon resection and colostomy. Defendant doctor later performed the colostomy reversal and repair of a hernia. During surgery, the plaintiff alleges, the defendant damaged her ureter. The defendant completed the procedure without realizing that the injury had occurred. Another surgery was required to repair the ureter.

The plaintiff hired a general surgery expert witness and filed a lawsuit in Pennsylvania Court of Common Pleas, asserting a claim for negligence.

Question(s) For Expert Witness

1. What should the surgeon have done?

2. Was failure to do it a breach of the standard of care?

Expert Witness Response

Identification and protection of the ureter in the operative field is a significant step in attempting to prevent injury. Regardless of whether it is difficult, it should always be attempted. It is preferable to visually identify the ureter, rather than assuming that blunt dissection of the rectum will move it out of harm's way. When inflammation or scar tissue in the pelvis renders visual identification impossible, then ureteral stents can be helpful. Furthermore, administration of methylene blue at the end of the case can aid in identification of an injured ureter, allowing for immediate repair - and reducing the potential for serious complications.

A more complex and difficult an operation near the ureter should compel the surgeon to trace its course and take appropriate action to avoid its injury. Often the ureter can be found easier in the less scarred tissue away from the pelvis and traced down.

Defendant admitted that he did not make any attempt at any time to identify the ureters. This omission, in my opinion, is a deviation from the standard of care and likely resulted in the injury of plaintiff’s ureter. While the use of ureteral catheters may not have prevented the injury, more likely than not it would have aided in the identification of the injury and made repair possible during the original operation, thus preventing the need for further surgery.

While defendant does report that vaginal cuff was entered during the rectal mobilization, he does not mention entering the bladder, which would likely have been obvious to him at that time. Therefore, while it is conceivable that the bladder could be entered at the same time as the vagina, it clearly was not, and the urine in the drain was from an injured ureter. I also do not believe that the injury to the ureter was a result of electrocautery. The finding of a transected ureter through which a stent could not be passed would seem to exclude this potential mechanism.